Commander Nursing Center Fails to Protect Residents From Abuse & Neglect

Commander Nursing Center was cited after the facility “failed to ensure that all residents remained free of abuse/neglect.” The facility did not do four vital things after three residents brought forth allegations of abuse/neglect:

1. Identity allegations/complaints as abuse/neglect;
2. Immediately implement safeguards to prevent further violations;
3. Report the allegations to appropriate authorities within the required time frames;
4. Conduct thorough investigations for the 3 residents who reported abuse/neglect.

According to the citation, staff members failed to assist Resident #1 with using the restroom when they requested help. Instead, staff members instructed the resident to use their disposable brief, which “would reasonably result in shame/humiliation.”

According to a Social Service note, the resident stated they put their call light on to get help using the restroom. When a Certified Nursing Assistant (CNA) answered the call light, the CNA told the resident to use the brief they were in. When the resident stated they would be wet, the CNA said “just do it.” The resident then wet themselves. The note also stated that the CNA was very short with the resident, but it’s not the first time the CNA has been “ugly” towards the resident.

Resident #2 reported that staff members were “rough and spoke abusively at times.” The resident was in a lot of pain due to previous broken hips, one of which was now inoperable and caused the resident “excruciating pain.” According to the resident’s complaint, a CNA was often rough with the resident and “fusses” with the resident at times. The investigator of this citation asked the resident how it made them feel when the CNA was rough with them; they began to cry and could not answer.

The investigator then interviewed the Director of Nursing (DON) regrading the rough handling. She stated she had not identified the CNA’s actions as abuse or “investigated [the complaint] as an allegation of abuse/neglect.” The DON said she talked to the staff, but there were no written statements.

Resident #3 did not receive help for incontinence over a 9 hour period. The resident stated they sat in a wet brief with a puddle under their chair from 7 AM to 4 PM. The resident also said that no one checked on them throughout the morning; the cubical curtain is usually pulled between them and a roommate, and the staff “does not usually come in to check on [the resident].” Documentation from the DON stated the following regarding the allegation: “After talking with staff, this did not occur. Resident experienced intermittent confusion.”

According to the citation, “There was no evidence of how the DON came to this conclusion. There was no evidence of any investigation of the complaint. There were no documented subsequent interviews with the resident in an attempt to validate the information. There were no written statements by staff or documented staff or roommate interviews. There was no evidence that the incident was reported to the State Agency.”

When abuse/neglect allegations come forward, there are many steps facilities must take to ensure the safety the residents. Commander Nursing Home’s neglect and abuse policy states the following:

When abuse, neglect, or exploitation is suspected, the Licensed Nurse should:

– Respond to the needs of the resident and protect them from further incident (document).
– Notify the Director of Nursing and Administrator (document).
– Initiate an investigation immediately.
– Notify the attending physician, resident’s family/legal representative and Medical Director.
– Obtain witness statements.
– Contact the State Agency and the local Ombudsman office to report the alleged abuse.

For all three residents, the proper procedures were not followed.

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